Sepsis

Question 1

Most common causes of sepsis

Answer 1

Gram positive
Methicillin resistant staphylococcus
Enterococcus
Fungi has risen in immunosuppressed

Question 2

Most common locations for sepsis infections

Answer 2

Pneumonia, intra-abdominal, urinary, skin/soft tissue

Question 3

General definition

Answer 3

Suspected or confirmed infection with evidence of systemic inflammation (demonstrated through evidence of immune response or lab results)

Question 4

Definition for severe sepsis

Answer 4

Sepsis plus evidence of new organ dysfunction thought to be secondary to tissue hypoperfusion

Question 5

Septic shock definition

Answer 5

Cardiovascular failure occurs, with infection, evidenced as persistent hypotension or need for pressures despite adequate pressors

Question 6

Mortality rates of infectious and non infectious sepsis

Answer 6

3% without SIRS
6% meeting two SIRS criteria
17% for those meeting all four

Question 7

Serum lactate

Answer 7

Excellent prognostic data in sepsis.
From tissue hypoperfusion.
28 day mortality rate of 15% with lactate 2-4mmol/L

Question 8

SIRS criteria

Answer 8

Temp <38.3 >36.0
Pulse rate >90min or 2 SD above normal for age
Tachypnea >20
Leukocytosis (WBC > 12,000 cells/uL) or leukopenia <4000 cells/uL, or normal WBC with 10% immature forms

Question 9

Sepsis signs

Answer 9

Fever, hypothermia
Tachycardia
Tachypnea
Altered LOC
Edema
Hyperglycemia
C-reactive protein
Hypotension (systolic <90, MAP <70)
Acute oliguria
INR >1.5 or PTT >60s 
Thrombycytopenia (too low) 
Elevated creatinine, bilirubin
Low platelets

Question 10

ED pts with undifferentiated hypotension

Answer 10

40% from infectious

Question 11

ARDS

Answer 11

New lung edema from increased alveolar and cap permeability

Question 12

Pulmonary injury

Answer 12

Doesn’t need pneumonia in sepsis, still can have ARDS.

Question 13

Classification of ARDS

Answer 13

Mild - PaO2/FiO2 of 200-300
Moderate 100-200
Severe <100
27% mortality in mild, 45% on severe

Question 14

Renal injury

Answer 14

Injury from hypoperfusion is a major factor, but also toxic products from neutrophil-endothelial interactions, and DIC

Question 15

Ileus

Answer 15

Lack of movement somewhere in intestines

Question 16

SIRS

Answer 16

Criteria does not confirm presence of infection or sepsis, it is simply a crude stratifcation of patients with systemic inflammation

Question 17

Hepatic injuries in sepsis

Answer 17

Infrequent but most likely cholestatic jaundice

Red blood cell hemolysis from microvascular coagulation can also rarely cause jaundice

Question 18

GI changes in sepsis

Answer 18

Ileus is most common, which may persist for days after shock resolves
Major blood loss is rare, but minor blood loss within 24 hours from painless eroisions of in the mucosal layer of stomach or duodenum are possible

Question 19

Cytosis/penia

Answer 19

Cytosis is too many, penia too few

Question 20

Piss in sepsis

Answer 20

Azotemia, oliguria, anuria

Question 21

Azotemia

Answer 21

High levels of nitrogen in urine

Question 22

Hematologic changes in sepsis

Answer 22

Neutropenia, Neutrophilia, thrombocytopenia, or DIC is all possible.
Neutropenia is rare but increases mortality rates
Red cell production is suppressed but anemia is unlikely unless it pre exists or the infection is extremely prolonged
Thrombocytopenia possible due to DIC, presents in <30%
If DIC happens, very poor prognosis

Question 23

Metabolic changes in sepsis

Answer 23

Lactate from tissue hypoperfusion
Hyperglycemia regardless of diabetes (bad prognosis if no beeties)
Hypoglycemia possible
Adrenal insufficiency from hypoperfusion, adrenal or pituitary hemorrhage, cytokine dysfunction, drug-induced hypermetabolism, inhibition of steroidogenesis and desensitization of glucocorticoid reponsiveness

Question 24

Skin (5 potential manifestations)

Answer 24

Direct bacterial (cellulitis, erysipelas, fasciitis)
Lesions from hematogenous seeding of skin (petechia, pustules, cellultis, ecythma gangrenosum)
Lesions from hypotension/ DIC (acrosyanosis, necrosis of peripheral tissue)
Lesions from intravascular infections (microemboli/ immuno complex vasculitis)
Lesions from toxic shock

Question 25

Sepis diagnosis

Answer 25

Suspicion of confirmation of infection, systemic inflammation, evidence of new organ dysfunction/tissue hypoperfusion.
Pressure <90 after fluid (30mL/kg or 1.5-3L)

Question 26

Differentials for severe sepsis

Answer 26

Other types of shock, cardiogenic, hypovolemic, anaphylatic, neurogenic or obstructive (PE, tamponade)
Endocrine disorders (adrenal insufficiency, thyroid storm) 
Children may not develop hypotension until late

Question 27

Most common sepsis trigger

Answer 27

Acute bacterial pneumonia

Question 28

Common triggers other than pneumonia

Answer 28

Acute pylonephritis (kidney infection)
Cholecystitis (Gallbadder inflammation)
Cholangitis (infection of bile duct)

Question 29

Acute pancreatitis

Answer 29

Can result in presentation identical to septic shock due to widespread inflammation

Question 30

Bloods

Answer 30

CBC with platelet count
Serum lytes
BUN and creatinine
Lactic acid level
Liver function panel (bilirubin, alkaline phosphate, aspartate and alanine aminotransferase levels) 
Urinalysis
ABG
Imaging

Question 31

TX sepsis

Answer 31

Early treatment of hemodynamic compromise and early infection control
Most pts need 2-5L in first 6 hours
Pressors
Antibiotics

Question 32

Saline resus

Answer 32

Hyperchloremic metabolic acidosis

Colloids not needed in early sepsis

Question 33

Stroke volume variation for fluid resus

Answer 33

Lift legs of supine pt for 60 seconds, improved BP indicates volume responsive pt

Question 34

Vasopressors

Answer 34

MAP of 65 is sought, higher is no better
Norepi at 0.5-30mcg/min
Dopamine has higher rate of complications and dysrhythmias.
Vasopressin as a second line
Epi 1-20mcg/min
Phenylephrine if tachydysrhythmias are a concern

Question 35

Postspenectomy pts

Answer 35

Pts without a spleen are increased risk for infection with encapsulated species such as salmonella or hameophilus influenzae